Reframing Super-Utilization: A Complex Systems Review of Cost-Focused Interventions in High-Need, High-Cost Care—Radical Transformation Is Needed

Super-utilization, defined as frequent and often avoidable use of emergency departments and hospital admissions, has attracted significant policy and research attention due to its impact on healthcare costs. Over the past decade, care management and integrated care interventions have been promoted as solutions to reduce per capita expenditure and service use. However, systematic reviews and primary studies consistently report limited success in shifting utilization patterns or improving care experiences. This narrative review based upon critical systems heuristics explores the conceptual evolution of super-utilization and examines whether current approaches reflect the underlying complexity of the health system and patient needs. The three-phase narrative and complexity-informed review aimed to identify the evolution of Super-utilization as an issue and its key drivers, in relation to the dynamic systems in which it occurs. The findings reveal a predominant emphasis on cost containment and acute care metrics, with minimal incorporation of person-centered outcomes, lived experience, or local system dynamics. Even when addressing social determinants, interventions remain narrowly focused on utilization and/or costs as the key outcome. Super-utilization or High-Need/High-Cost trajectories reflect multi-level dynamics—biological, psychological, social, and political—yet these are rarely integrated into program design or evaluation. Centralized policy frameworks such as the Triple Aim risk reinforce inequities unless they actively address under-resourced populations and the complexity of chronic illness and ageing. Radical transformation of policy is required to make the nature of care of high-cost/high-need super-utilizers central to quality metrics that may improve outcomes rather than inappropriate utilization metrics which make little impact on healthcare costs. This review concludes that super-utilization requires a shift in paradigm toward systems-informed, needs-based approaches that integrate complexity theory and distributive justice to guide future research and interventions.